GW1-2021-00392_Well Construction - GW1_20211230

WELL CONSTRUCTION REC ?D (GW_1) For Internal Use On
1.Well Contractor In ormation:
-
WellContractorName FROM TO DESCRIPTION
2?5L
ft.
ft. ft.
NC W ll Contractor CertiFlcationNumber (#TER CASINO for�mutti caset7:we115 fllisLlNER .. iican►e
l�l �� ) F�M ft i/_�fL_. U14hI N;l'kR in. �CKNM.SS M4'ft:R1A1
Company Name IVA�/Y�s wto
VC
6.2, I DODI(o
FROM�^� ER C To)'NC OR TFlH1NG'"eothc'r'iD
W20 a1 t#oscd Ip0°'
2.Well Construction Permit#: DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.Counm.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in,
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) :Residential Water Supply(single) ft. ft. in,
industrial/Commercial Residential Water Supply(shared) _...-.�: ......:. ....ties ._.�.'�'
Irrigation FROaI 910 NIATERIAI. FMPI•ACFMFNTNIF•THOD&ARIOUN'I'
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
U
Injection Well: 1
ft. ft.
Aquifer RechargeGroundwater Remediation
39:"S11VAlGR 1VEL PACK'rf">f fable?
Aquifer Storage and Recovery r3Salimry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) E]Tracer 20.DRILLING LOG attach additiui itl sfieets.if iecessa. <r
Geothermal(HeatinglCoolingRcturn) 'Other(explain under#21 Remarks) '^FROM ft. TO� ft. /1
DESCRIPTION color,hardness,soil/mck e, in size,etc.
4.Date Well(s)Completed:?-14�21 Well iD# V
5a.Well Location:
M.
I' •7!
Facility/Owner Nude Facility lD#(ifapplicabie) ft. .ft.
`IZ P>oS Qc ft. ft. DEC 3 0 2021
Physical Address,City,and 2ip
�,
21:REMARKS ...
�o RXD L °.- INF '!P`Grp i JNI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if� r
wjellfield,on/e]aadlong-iiss sufficient)
il s�1.� /�cient) 22. rtification: ' ,I
Mill
6.ls(are)the well(s)ofermanent or OTemporary Signature o -rtified W etl Contractor Dare
�,/ ,ry.signing this larin,/hereby ceruh,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes orS Po with 15.4 NCAC 02C.0100 or 15A NCAC 02C.02U0 Well Construction Standards and that a
f this is a repair.fill out knourn well construction information and explain the nature gf the coley of this record has been provided to the un[l owner.
repair under 921 rentarkr section or on the back of this fiirm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2/ v (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it'dijf-erew(example-?(&,200'and 2(a 101t') construction to the following:
I
10.Static water level below top of casing: 1 DO (ft.) Division of Water Resources,information Processing Unit,
1/'water level is above casing,use"+" 1617 Mail Service icenter,Raleigh.NC 27699-1617
11.Borehole diameter: lY (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
j� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: /�/d Arc/ fonstruction to the following:
(i.e.auger,rotary,cable,direct push,etc.) t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServiceCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: / 24,c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 'AllAmount. I U completion of wel I construction;to,the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water ResourcCL s Revised 2-22 201fi
I